First 500,000 AIDS Cases -- United States, 1995

As of October 31, 1995, a total of 501,310 persons with
acquired
immunodeficiency syndrome (AIDS) had been reported to CDC by state
and
territorial health departments; 311,381 (62%) had been reported as
having
died. The AIDS surveillance case definition was substantially
expanded in
late 1987 and again in 1993 to reflect increased knowledge of the
natural
history of human immunodeficiency virus (HIV) and to remain
consistent with
the clinical management of HIV disease (1,2). This report presents
rates of
reported AIDS cases for 1994 and describes the temporal changes in
the
characteristics of persons reported with AIDS during three periods
corresponding to changes in the AIDS case definition -- 1981-1987,
1988-
1992, and 1993-October 1995 -- and how this information can be used
to plan
local, state, and national prevention programs. *

Of the cumulative AIDS cases, 50,352 (10%) were reported during
1981-1987, 203,217 (41%) during 1988-1992, and 247,741 (49%) during
1993-October 1995. The proportion of AIDS cases among females
increased
from 8% of cases reported during 1981-1987 to 18% during
1993-October 1995
(Table_1). The proportion of cases among whites decreased from
60% to
43%, and the proportion among blacks and Hispanics increased from
25% to
38% and from 14% to 18%, respectively. During 1994, the rates per
100,000
population for blacks and Hispanics (101 and 51, respectively) were
substantially higher than rates for whites (17), American
Indians/Alaskan
Natives (12), and Asians/Pacific Islanders (6).

The proportion of cases among persons who reported
injecting-drug use
increased from 17% during 1981-1987 to 27% during 1993-October
1995, and
the proportion of cases attributed to heterosexual transmission
increased
from 3% to 10%. Cases among men who have sex with men decreased
from 64% to
45%.

During 1994, the rates per 100,000 population for reported AIDS
cases
were 48 in the Northeast, 31 in the South, 29 in the West, and 13
in the
Midwest. ** However, during 1988-1992 and 1993-October 1995, the
largest
numbers of cases (65,926 and 86,462, respectively) were reported
from the
South, which also accounted for the largest proportionate increase
of
reported cases (31%). The proportionate increases in reported cases
from
1988-1992 to 1993-October 1995 for the Midwest, Northeast, and West
were
22%, 20%, and 15%, respectively.

During 1993-October 1995 in the South and Midwest, higher
proportions
of cases among adolescents and young adults (aged 13-29 years)
occurred in
small (50,000-499,999 population) metropolitan statistical areas
(MSAs) and
non-MSAs (rural areas) (27% and 24%, respectively) compared with 9%
in the
Northeast and 11% in the West. During this time period, among cases
in
adolescent and young adult men who have sex with men, 25% of 8481
cases in
the South occurred in persons who resided in small MSAs and rural
areas,
21% of 2870 in the Midwest, 9% of 3311 in the Northeast, and 9% of
5706 in
the West. Among adolescent and young adult injecting-drug users,
30% of 531
cases in the Midwest occurred among persons residing in small MSAs
and
rural areas, 23% of 2370 in the South, 17% of 930 in the West, and
8% of
3304 in the Northeast. The proportion of cases among adolescents
and young
adults residing in small MSAs and rural areas that resulted from
heterosexual transmission was highest in the South (32% of 2842),
followed
by the Midwest (22% of 678), the West (18% of 691), and the
Northeast (7%
of 1745).

During 1993-October 1995, most AIDS cases among adolescent and
young
adult men who have sex with men occurred among whites in all four
regions
(Midwest, 57%; West, 56%; South, 49%; and Northeast, 42%). Black
adolescent
and young adult men who have sex with men accounted for 39% of
cases in the
South, 37% in the Midwest, 36% in the Northeast, and 14% in the
West. These
proportions were higher than those for cases among black adolescent
and
young adult men who have sex with men reported during 1988-1992
(South,
31%; Midwest, 30%; Northeast, 31%; and West, 12%).

Editorial Note

Editorial Note: The World Health Organization estimates that 18
million
adults and 1.5 million children have been infected with HIV,
resulting in
approximately 4.5 million AIDS cases worldwide (3). The theme for
the 1995
World AIDS Day (December 1) is "Shared Rights, Shared
Responsibilities."
The findings in this report document both the magnitude and
evolving nature
of the AIDS epidemic in the United States, and underscore that
HIV-prevention programs must be planned and implemented
collaboratively by
persons with diverse skills, training, and experience.

In addition to describing the overall magnitude of the epidemic
--
approximately one half million cases, nearly half of which have
been
reported since 1993 -- this report highlights changes in the
epidemiologic
patterns during 1993-October 1995 compared with those during
earlier
periods. In particular, although men who have sex with men continue
to
account for the largest proportion of cases, the AIDS epidemic is
increasing more rapidly among injecting-drug users and persons
infected
through heterosexual contact with a partner at risk for or known to
have
HIV infection or AIDS (4,5). The increase in AIDS cases resulting
from
heterosexual transmission also is reflected in the increase in
cases
reported among women. The proportions of AIDS cases reported during
1993-October 1995 that are attributed to these risk behaviors will
increase
as records of persons who were reported initially without risk are
reviewed
and the risk is identified (6). Geographic patterns also have
changed, as
reflected by increases occurring among persons in the South.
Finally,
regardless of transmission mode or region, the epidemic continues
to affect
blacks and Hispanics disproportionately.

Although the AIDS epidemic in the United States was recognized
initially in the Northeast and West (7), and rates remain highest
in the
Northeast, the findings from AIDS surveillance document that the
greatest
proportionate increases in the HIV epidemic have occurred in the
South and
Midwest -- areas that account for the largest proportion of the
total U.S.
population. These regional variations, especially in adolescents
and young
adults, underscore the importance of developing HIV-prevention
programs
based on local trends in the epidemiology of HIV transmission. In
the South
and Midwest, more detailed characterization of the epidemiologic
patterns
in small cities and rural areas is particularly important for
developing
effective regionwide prevention programs.

The disproportionate impact of the epidemic among racial/ethnic
minorities is reflected by rates of reported AIDS cases that are
six and
three times higher for blacks and Hispanics, respectively, than for
whites.
Rates for HIV infection and the proportions of men who have sex
with men
and injecting-drug users with AIDS who are black and Hispanic also
vary
substantially by region (8). For example, Hispanics account for
lower
proportions of reported cases of AIDS among adolescents and young
adult men
who have sex with men in the Midwest and South than in the
Northeast and
West. Because race and ethnicity are not risk factors for HIV
transmission,
programs to prevent HIV transmission among racial/ethnic minorities
should
be based on underlying social, economic, and cultural factors that
influence risk behaviors (8).

Because of the regional and local variations in the AIDS
epidemic in
the United States, HIV-prevention efforts must be directed at the
local
level. In 1993, a CDC advisory committee review of HIV-prevention
programs
emphasized the importance of 1) enhancing the capacity of local and
state
agencies to collect and analyze information relevant to the
specific and
unique aspects of HIV transmission in their communities, 2)
strengthening
the behavioral and social science bases of HIV-prevention
activities, and
3) ensuring that HIV-prevention strategies and interventions
reflect the
preferences and needs of the affected communities for whom they are
intended (9). As a result, in 1994, CDC initiated the HIV
Prevention
Community Planning process (10) that has provided resources for
collaboration between health departments and planning groups that
are
representative of the local communities. These resources facilitate
HIV-prevention programs that are based on scientific data
(including data
from HIV/AIDS surveillance, seroprevalence surveys, vital
statistics, and
behavioral research) and knowledge of the community norms and
practices.
This approach is consistent with the focus of World AIDS Day and
emphasizes
the necessity of shared participation in HIV-prevention planning
and
program implementation.

Single copies of this report will be available free until
November 22,
1996, from the CDC National AIDS Clearinghouse, P.O. Box 6003,
Rockville,
MD 20849-6003; telephone (800) 458-5231 or (301) 217-0023.

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